ObjectivesTo determine whether the prevalence of chronic kidney disease (CKD) in England has changed over time.DesignCross-sectional analysis of nationally representative Health Survey for England (HSE) random samples.SettingEngland 2003 and 2009/2010.Survey participants13 896 adults aged 16+ participating in HSE, adjusted for sampling and non-response, 2009/2010 surveys combined.Main outcome measureChange in prevalence of estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 (as proxy for stage 3–5 CKD), from 2003 to 2009/2010 based on a single serum creatinine measure using an isotope dilution mass spectrometry traceable enzymatic assay in a single laboratory; eGFR derived using Modified Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) eGFR formulae.AnalysisMultivariate logistic regression modelling to adjust time changes for sociodemographic and clinical factors (body mass index, hypertension, diabetes, lipids). A correction factor was applied to the 2003 HSE serum creatinine to account for a storage effect.ResultsNational prevalence of low eGFR (<60) decreased within each age and gender group for both formulae except in men aged 65–74. Prevalence of obesity and diabetes increased in this period, while there was a decrease in hypertension. Adjustment for demographic and clinical factors led to a significant decrease in CKD between the surveyed periods. The fully adjusted OR for eGFR <60 mL/min/1.73 m2 was 0.75 (0.61 to 0.92) comparing 2009/2010 with 2003 using the MDRD equation, and was similar using the CKDEPI equation 0.73 (0.57 to 0.93).ConclusionsThe prevalence of a low eGFR indicative of CKD in England appeared to decrease over this 7-year period, despite the rising prevalence of obesity and diabetes, two key causes of CKD. Hypertension prevalence declined and blood pressure control improved but this did not appear to explain the fall. Periodic assessment of eGFR and albuminuria in future HSEs is needed to evaluate trends in CKD.

PURPOSE We examined quality, satisfaction, fi nancial, and productivity outcomes associated with implementation of Care by Design (CBD), the University of Utah's version of the patient-centered medical home. METHODSWe measured the implementation of individual elements of CBD using a combination of observation, chart audit, and collection of data from operational reports. We assessed correlations between level of implementation of each element and measures of quality, patient and clinician satisfaction, fi nancial performance, and effi ciency. RESULTSTeam function elements had positive correlations (P ≤.05) with 6 quality measures, 4 patient satisfaction measure, and 3 clinician satisfaction measures. Continuity elements had positive correlations with 2 satisfaction measures and 1 quality measure. Clinician continuity was the key driver in the composite element of appropriate access. Unexpected fi ndings included the negative correlation of use of templated questionnaires with 3 patient satisfaction measures. Trade-offs were observed for performance of blood draws in the examination room and the effi ciency of visits, with some positive and some negative correlations depending on the outcome.CONCLUSIONS Elements related to care teams and continuity appear to be key elements of CBD as they infl uence all 3 CBD organizing principles: appropriate access, care teams, and planned care. These relationships, as well as unexpected, unfavorable ones, require further study and refi ned analyses to identify causal associations. Ann Fam Med INTRODUCTIOND espite widespread pilot implementation and favorable initial results of the patient-centered medical home (PCMH), 1 assessment of its impacts is in an early stage.2 Not enough is known about the model's implications to ascertain its results in terms of practice quality, satisfaction, or fi nances.3 Evidence is also lacking about relationships between individual elements of the PCMH model and specifi c benefi cial outcomes.In this study, in contrast to looking at the PCMH as a whole, we examined the relationship between individual elements of Care by Design (CBD), a comprehensive redesigned model of care that incorporates many elements of a PCMH, and multiple outcomes in quality of care, patient and clinician satisfaction, productivity, and operational costs.The University of Utah's Community Clinics introduced CBD in 2003. The model had 3 founding principles: appropriate access, care teams, and planned care. The transformation included expanded and new roles for support staff and redesigned workfl ows and processes. Implementation initially focused on improved access with an emphasis on same-day appointments. Appropriate access was designed primarily to improve patient satisfaction. By 2006, the model had incorporated additional elements including team-based care and more comprehensive planned care. Care teams enhanced effi ciency by using the time and skills of support staff, allowing clinicians to focus more on relationships with patients. Medical assistants (MAs)...

Objectives Assess 1) provider satisfaction with specific elements of PCMH; 2) clinic organizational cultures; 3) associations between provider satisfaction and clinic culture. Methods Cross sectional study with surveys conducted in 2011 with providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design™. Measures included the Organizational Culture Assessment Instrument (OCAI) and the American Medical Group Association provider satisfaction survey. Results Providers were most satisfied with quality of care (M=4.14; scale=1–5) and interactions with patients (M=4.12) and least satisfied with time spent working (M=3.47), paper work (M =3.45) and compensation (M=3.35). Culture profiles differed across clinics with family/clan and hierarchical the most common. Significant correlations (p ≤ 0.05) between provider satisfaction and clinic culture archetypes included: family/clan negatively correlated with administrative work; entrepreneurial positively correlated with the Time Spent Working dimension; market/rational positively correlated with how practices were facing economic and strategic challenges; and hierarchical negatively correlated with Relationships with Staff and Resource dimensions. Discussion Provider satisfaction is an important metric for assessing experiences with features of a PCMH model. Conclusions Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.